October 2023

Advanced Concepts In Breast Augmentation: Bottoming Out

Bottomed Out Breast Implants

Breast augmentation continues to be one of the most popular cosmetic procedures with one of the highest satisfaction rates in all of plastic surgery. The procedure delivers reliable and transformational results for thousands of women each year, and it's a top procedure in my Dallas plastic surgery practice.

Breast augmentation complications are relatively rare, but they can occur. One undesired outcome is bad implant positioning. Implant malposition occurs when the breast implant pocket stretches, causing the implants to rest in an unwanted position. When gravity's effect on the implant and breast tissue stretches beyond what is normal, we refer to that as "bottoming out."

Breast Architecture

The breast fold is also known as the inframammary breast crease which clearly separates the lower breast from the chest and has a well-defined curvilinear shape. The inframammary breast crease is formed from fascial attachments to the chest.

The most common method of breast augmentation involves placing the incision in the breast crease so it's well-concealed in most movements and positions like sitting or standing. The inframammary (IMF incision) is popular because:

  • It gives plastic surgeons the best visualization for the dissection of the implant pocket.
  • It allows direct access to the pectoralis muscle for under-the-muscle breast augmentation, and
  • it is the least painful and has the lower number of complications.

The Inframammary Surgical Technique

During breast augmentation surgery, your plastic surgeon should carefully dissect away from the inframammary crease toward the upper chest and collarbone. It's important to preserve the structure and anatomic proportions of a woman's natural breast tissue, so experienced plastic surgeons almost never lower the breast fold.

What's considered normal female breast anatomy?

Normal female anatomy demonstrates a nipple-to-breast fold distance of about 5 to 7 cm. in most women. This measurement is critical in achieving optimal results in breast augmentation and preventing bottoming out.

Unpredictable Stretching Can Happen

However, even in the best of circumstances, this distance between the nipple-to-IMF fold can stretch creating a significant distance that causes the implant to drop and sit too low. When the majority of the implant sits below the nipple-areolar complex, this is termed bottoming out.

Bottoming Out Presents In 3 Major Ways

Before and after lateral displacement, bottomed out breast implants by Dallas plastic surgeon, Dr. John Burns

Inferior Malposition

Lower malposition of the implants happens when the device migrates down, making the breast augmentation result too low on the chest wall and breast crease (inframammary fold).

Lower Pole Stretching

Lower pole stretching is observed when the breast implant stays in the correct position, but the skin at the lower part of the breasts stretches significantly.

Lateral Displacement

Lateral implant malposition occurs when the implants fall too far to the side when the patient lies down. Many women complain that their implants feel like they slide into their armpits when they lie down. This can be due to over-dissection of the lateral breast pocket or stretching of the breast skin over time.

Bottoming out is more common in periareolar (around the areolae) or endoscopic trans-axillary (through the underarm) techniques where the dissection is directed towards the breast fold making weakening of the fold more likely. Specifically in the trans-axillary approach, the breast fold is lowered so that bottoming out is an even greater possibility.

Check out our blog: 3 Signs You Need New Breast Implants

Dallas Breast Revision Before and After by Dr. John Burns 

Correcting Bottomed-out Breast Implants

The breast fold itself has become weakened and stretches the lower breast pole skin envelope. The remedy involves reconstructing the implant pocket so that it perfectly fits the dimensions of the implant and holds the implant in the correct position. Usually, this is accomplished by placing a permanent suture below the skin to close off the implant pocket on the side and to reinforce the breast fold at its normal anatomic position (5–7 cm from the nipple). Placing these sutures is called a capsulorrhaphy.

Some surgeons will cauterize the implant capsule with electrocautery in a process called “pop-corning” to both strengthen and shrink the implant capsule before placing reinforcing sutures. Many surgeons will also use synthetic mesh like Galaflex or Durasorb, to reinforce the repair and keep tension off the lower pole and lateral breast tissue and skin. When synthetic reinforcing mesh is used this is often called an “internal bra.”

Seek Out An Experienced Breast Revision Specialist

Bottoming out can be corrected in breast revision surgery. The procedure itself requires skill and precision. The goal of correction is to reposition the implant by precisely reconstructing the implant pocket to re-establish perfect breast dimensions and meet aesthetic goals. It's really important that you consult with an experienced board-certified plastic surgeon to ensure your concerns are corrected the first time and to prevent additional procedures in the future. 

Follow Proper Post-care To Ensure Optimal Healing

Preventing implant displacement is always preferable. Precise surgical pocket dissection is the first step ensuring the breast fold remains intact and not weakened. After surgery, it is advised to always wear a bra to support the implant and keep the weight off the lower pole soft tissue and breast crease. When exercising and running, it is very critical to make sure the breasts are well supported. Good skin care is helpful to keep the breast skin healthy and hydrated. Good skin quality will help support the implant.

Before and After Breast Revision by Dallas Plastic Surgeon, Dr. John Burns

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